Stronger Laws Are Needed to Protect Teens From

Stronger Laws Are Needed to Protect Teens From Indoor Tanning The article by Balaraman et al1 in this issue of Pediatrics examines practices of indoor tanning facilities in Missouri, 1 of 17 states with no regulations regarding minors’ use of these facilities. More than twothirds of respondents working at the facilities stated that they would allow children as young as 10 to 12 years old to tan, some without parental consent. More than 40% claimed that there were no tanningassociated health risks. The study’s findings are alarming but unfortunately not surprising given that there is no law in Missouri protecting minors from indoor tanning. Indoor (“artificial”) tanning is a $5 billion dollar industry with 19 000 freestanding salons employing 160 000 individuals.2 Tanning is inexpensive. Access is easy with more tanning salons in an average city than Starbucks or McDonald’s.3 Tanning is especially popular with teenage girls and young women. Data from the national 2009 Youth Risk Behavior Survey show that 15.6% of high school students (including 25.4% of girls) used an indoor tanning device $1 times in the past year; 49% of all patrons (especially female and white students) used them $10 times in the past year.4 Indoor tanning has severe health consequences. Molecular evidence reveals that DNA damage is an integral part of the tanning response,5,6 refuting the concept of the “safe tan.” Epidemiologic evidence increasingly links artificial tanning to higher skin cancer risk, including melanoma risk7–11; risk increases when tanning starts at an early age.7,8 Melanoma incidence has risen dramatically in recent years, especially in young women.12 There will be about 76 690 new melanomas diagnosed in the US in 2013, and about 9480 people are expected to die from melanoma.13 Although the prognosis is excellent when melanoma is detected early, metastatic disease remains deadly. Each year, young people are among those who succumb to melanoma.

AUTHORS: Sophie J. Balk, MD,a David E. Fisher, MD, PhD,b and Alan C. Geller, RN, MPHc a

Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York; bDepartment of Dermatology, Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and c Harvard School of Public Health, Massachusetts General Hospital, Boston, Massachusetts KEY WORDS indoor tanning, artificial tanning, tanning legislation, teenagers, skin cancer, melanoma, prevention, tanning legislation ABBREVIATION FDA—US Food and Drug Administration Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. www.pediatrics.org/cgi/doi/10.1542/peds.2012-3367 doi:10.1542/peds.2012-3367 Accepted for publication Dec 4, 2012 Address correspondence to Sophie J. Balk, MD, 1621 Eastchester Rd, Bronx, NY 10461. E-mail: sbalk@montefiore.org PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. COMPANION PAPER: A companion to this article can be found on page 415, and online at www.pediatrics.org/cgi/doi/10.1542/ peds.2012-1781.

The International Agency for Research on Cancer has stated that UV radiation-emitting tanning devices are carcinogenic to humans.14 The World Health Organization, the American Academy of Pediatrics, the American Academy of Dermatology, and others recommend that legislation ban minors from indoor tanning. Nations including the United Kingdom, France, and Germany have banned teen tanning.15 Brazil and the state of New South Wales in Australia banned indoor tanning for everyone. In the United States, the US Food and Drug Administration (FDA) regulates tanning beds as class I medical devices, the same category as tongue depressors and elastic bandages. Although the FDA recommends that specific precautions be taken when consumers use an indoor tanning facility,16 the agency places no age restrictions. It is therefore up to state governments to regulate minors’ use of these devices, including imposing age restrictions. In October 2011, California 586

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became the first state to ban under-18 salon tanning; Vermont followed in May 2012. As of November 2012, 33 states had some kind of restriction regarding salon use by teens. Some states place bans at 14, 15, or 16 years of age; New York passed an under-17 ban in July 2012. Some states require that a parent accompany his or her child younger than a certain age; some require written consent, or written consent with the parent physically present, or a physician’s order or prescription.17 In 2011–2012, tanning bed legislation was introduced in states, including Missouri, with no legislation regarding minors.17 Pediatricians can advocate for new enforceable age bans and advocate for stronger laws in the majority of states that still allow minors younger than 18 years to tan. For most pediatricians, our main

According to the FDA, the “agency is considering revising some requirements for tanning beds, including strengthening the warning labels to make consumers

more aware of the risks.”20 Far stronger laws are required to protect youth and young women who frequent tanning beds at unprecedented rates. Given that one-third of states have no laws of any kind regulating minors’ anning-bed use, and nearly all remaining states have a patchwork of regulations such as age bans, parental consent, or performance standards, it is incumbent upon the FDA to enact a national under-18 salon tanning ban. Without strong FDA authority, the current approach will not work to protect the millions of teens in the 17 states with no laws, or those in the majority of states with weak restrictions. For those states that recently passed age bans, new battles will arise, including funding states to mandate enforcement of these laws.

of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer. 2007;120(5): 1116–1122 Cust AE, Armstrong BK, Goumas C, et al. Sunbed use during adolescence and early adulthood is associated with increased risk of early-onset melanoma. Int J Cancer. 2011;128(10):2425–2435 Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM. Indoor tanning and risk of melanoma: a casecontrol study in a highly exposed population. Cancer Epidemiol Biomarkers Prev. 2010;19(6):1557–1568 Veierød MB, Adami HO, Lund E, Armstrong BK, Weiderpass E. Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi. Cancer Epidemiol Biomarkers Prev. 2010;19(1): 111–120 Boniol M, Autier P, Boyle P, Gandini S Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012; 345:e4757. Available at: www.bmj.com/content/ 345/bmj.e4757.full?rss51&utm_source5 feedburner&utm_medium5feed&utm_ campaign5Feed%253A1bmj%252Frecent1

%28Latest1from1BMJ%. Accessed October 29, 2012 Purdue MP, Freeman LE, Anderson WF, Tucker MA. Recent trends in incidence of cutaneous melanoma among US Caucasian young adults. J Invest Dermatol. 2008;128 (12):2905–2908 American Cancer Society. What are the key statistics about melanoma skin cancer? Available at: www.cancer.org/cancer/skincancer-melanoma/detailedguide/melanomaskin-cancer-key-statistics. Accessed January 18, 2013 The International Agency for Research on Cancer. Sunbeds and UV radiation. Available at: www.iarc.fr/en/media-centre/iarcnews/ 2009/sunbeds_uvradiation.php. Accessed October 29, 2012 Lim HW, James WD, Rigel DS, Maloney ME, Spencer JM, Bhushan R. Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: time to ban the tan. J Am Acad Dermatol. 2011;64(5): 893–902 US Food and Drug Administration. Policy on maximum timer interval and exposure schedule for sunlamp products, August 1986. Available at: www.fda.gov/downloads/

influence is in the office. Most pediatricians do not discuss indoor tanning with teens and families.18 This situation should change: skin cancer prevention should become a regular discussion topic. The US Preventive Services Task Force concluded that counseling by primary care clinicians may reduce indoor tanning among late-adolescent women and recommended counseling fair-skinned children, teens, and young adults aged 10 to 24 years about minimizing UV radiation exposure.19 Parents should be included in these discussions. These conversations may prevent skin cancer in some patients and are opportunities we should not miss.

REFERENCES 1. Balaraman B, Biesbroeck L, Lickerman S, Cornelius L, Jeffe D. Practices of unregulated tanning facilities in Missouri: implications for statewide legislation. Pediatrics. 2013;131(3):415–422 2. Indoor Tanning Association. Frequently asked questions. Available at: www.theita.com/ ?page5FAQs. Accessed October 29, 2012 3. Hoerster KD, Garrow RL, Mayer JA, et al. Density of indoor tanning facilities in 116 large U.S. cities. Am J Prev Med. 2009;36(3): 243–246 4. Guy GP Jr, Tai E, Richardson LC. Use of indoor tanning devices by high school students in the United States, 2009. Prev Chronic Dis. 2011;8(5):A116. Available at: www.cdc.gov/pcd/issues/2011/sep/10_0261. htm. Accessed October 29, 2012 5. Cui R, Widlund HR, Feige E, et al. Central role of p53 in the suntan response and pathologic hyperpigmentation. Cell. 2007; 128(5):853–864 6. Fisher DE, James WD. Indoor tanning— science, behavior, and policy. N Engl J Med. 2010;363(10):901–903 7. The International Agency for Research on Cancer Working Group on Artificial Ultraviolet (UV) Light and Skin Cancer. The association

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Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/HomeBusinessand Entertainment/UCM192707.pdf. Accessed October 29, 2012 17. National Conference of State Legislatures. Indoor tanning restrictions for minors. Available at: www.ncsl.org/issuesresearch/health/indoor-tanning-restrictions-

for-minors.aspx. Accessed October 29, 2012 18. Balk SJ, O’Connor KG, Saraiya M. Counseling parents and children on sun protection: a national survey of pediatricians. Pediatrics. 2004;114(4):1056–1064 19. Moyer VA; US Preventive Services Task Force. Behavioral counseling to prevent

skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(1):59–65 20. US Food and Drug Administration. Indoor tanning: the risks of ultraviolet rays. Available at: www.fda.gov/forconsumers/ consumerupdates/ucm186687.htm. Accessed October 29, 2012

YOUR DAILY MULTIVITAMIN TO PREVENT CANCER: For many, the morning routine involves brushing one’s teeth, eating breakfast, and taking a daily multivitamin. While originally intended to prevent malnutrition, a recent study discussed in The New York Times (Well: October 22, 2012) demonstrated that daily multivitamins reduce the risk for malignancy. In a randomized, doubleblinded, placebo-controlled study, 14,641 male physicians initially aged 50 years or older were assigned to take either a daily common multivitamin or placebo, and were followed from the trial initiation in 1997 until 2011 for the development of cancers. When compared to the placebo group, the men taking a daily multivitamin experienced 8% fewer cancers. Multivitamin consumption was associated with a smaller but statistically insignificant decrease in cancer death. However, there was no reduction in cancer incidence for specific diagnoses such as prostate or colorectal cancer. While 8% is not a large reduction, in the general population the effects could add up. Others argue that other health interventions, such as smoking cessation are likely to have a far greater impact on cancer incidence. Moreover, the trial was conducted only in men who were generally healthier, had better diets, smoked less, and were more fit than the general population. While many may interpret the study findings as a reason for vitamin supplementation, it is important to recognize that previous investigations into the beneficial effects of vitamins have had decidedly mixed results. Some studies have even ended early because of an increased risk of cancer. In addition, there is always a possibility that taking more than the recommended daily dose of vitamins could have detrimental effects. Despite this study’s strength, more research is needed to support firmly a confirmation of the benefit of a daily morning multivitamin in addition to brushing one’s teeth. Noted by Leah H. Carr, BS, MS-III

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.


Stronger Laws Are Needed to Protect Teens From Indoor Tanning Sophie J. Balk, David E. Fisher and Alan C. Geller Pediatrics 2013;131;586; originally published online February 25, 2013; DOI: 10.1542/peds.2012-3367

The online version of this article, along with updated information and services, is located on the World Wide Web at: /content/131/3/586.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
